EMT-Basic Exam: The Basics of Medical Emergencies - Obstetrics and Gynecology

This section of the EMT-Basic exam tests your ability to deal with emergencies regarding pregnancy, labor, and the female reproductive system. You will also be tested on how to deliver a child, normal and abnormal delivery, and other gynecological emergencies.
About 16 percent of the questions on the EMT-Basic exam will cover obstetrics and gynecological issues.

1. Parts of the Reproductive System
You should already be familiar with the different parts of the female reproductive system, so this section should serve as an overview of the function of the various organs.
The fetus, or unborn baby, develops and grows inside the mother’s uterus for about 40 weeks. This amount of time is called the gestational period. The uterus, also called the womb, is the organ responsible for contracting and expelling the fetus during childbirth. The cervix, also called the neck of the uterus, is the organ that widens, or dilates, during labor and allows the fetus to pass through. After the fetus passes through the cervix, it makes its way through the birth canal, which is the lower part of the uterus and vagina. The fetus is expelled through the vagina when the mother pushes during labor.

During pregnancy, an organ called the placenta develops. The placenta is responsible for passing oxygen and nutrients from the mother to the fetus and the passing of waste and carbon dioxide from the fetus to the mother. These exchanges are done through the umbilical cord, which attaches the fetus to the placenta. The placenta is expelled during labor and the EMT-Basic cuts the umbilical cord from the newborn.
Inside the uterus, the fetus is surrounded by a bag of fluid called the amniotic sac, which contains amniotic fluid that helps cushion and protect the fetus. During labor, this sac breaks and releases the amniotic fluid, which lubricates the birth canal.




View of the female reproductive system.

2. Labor
Usually when an ambulance is called for a woman in labor, it’s the job of EMS personnel to transfer the patient to the hospital for delivery. Sometimes, there’s not enough time to make it to the hospital and the EMTs must assist the patient with the delivery. You should be familiar with the contents of the obstetrical kit, which contains a scalpel, clamps, and sterile gloves. Additional items in this kit may include scissors, ties, a bag for the placenta, and a “bunting cap” to keep the baby’s head warm.
 

Labor is the process of giving birth. It is divided into three stages.

The first stage of labor begins when the uterus begins to contract, moving the fetus into the birth canal. A woman in this stage of labor may feel strong and sometimes painful contractions. Her cervix dilates to prepare to pass the baby.
After a woman’s cervix has dilated to 10 cm, she has entered the second stage of labor. During the second stage, the fetus moves from the birth canal through the vagina. During a normal birth, you will most likely see the baby’s head in the vaginal opening. This is called crowning. After the baby is born, the mother enters the third stage of labor, in which the mother expels the placenta.

3. Predelivery Problems
Sometimes complications arise before the baby is ready to be born. Problems can be caused by medical conditions or trauma. In certain instances, the cause of these problems remains unknown.

Tip: In a traumatic emergency, a pregnant patient should be treated the same way as other patients with the same signs and symptoms.

a. Miscarriage
A miscarriage occurs when the fetus is delivered before it can survive on its own. This usually occurs during the first three months of pregnancy. Some of the signs of a miscarriage are abdominal cramping and heavy bleeding. The bleeding is usually accompanied by a discharge of clots of tissue. The following steps will help you treat a woman who is experiencing a miscarriage:

1. Treat the woman for signs and symptoms.

2. Call advanced life support (ALS) for assistance.

3. Administer oxygen.

4. Apply external vaginal pads or sanitary pads to reduce the blood flow.

5. Be prepared to treat shock symptoms if they appear.

6. Offer her emotional support, if needed.

b. Seizures
Sometimes a woman will develop medical conditions during pregnancy that cause seizures. Preeclampsia is a medical condition that causes a pregnant woman’s blood pressure to rise. It also causes weight gain and water retention. If seizures are present with this condition, the woman is experiencing eclampsia. This condition usually affects women who have had no prior history of seizures. ALS should be called to assist with these types of EMS calls.

c. Vaginal Bleeding
Many conditions can cause vaginal bleeding late in the pregnancy. This bleeding most often indicates a problem with the placenta, such as abruption placentae, a condition in which the placenta detaches from the uterus. Another condition that causes bleeding is called placenta previa, a condition in which the placenta implants over the cervix. ALS should be called to assist with these types of EMS calls.

d. Trauma
Sometimes a pregnant woman experiences a trauma that can cause problems for her and her fetus. The following special considerations should be observed when treating a pregnant trauma patient:
- Transport the woman on her left side to relieve the pressure on the vena cava from the weight of the uterus. If spinal injury is suspected, secure the woman on a long backboard, and then tilt the board to the left.
- Administer oxygen.
- Be prepared for vomiting, as digestion slows during pregnancy.
- Be prepared to treat shock symptoms if they appear.
- In the event of the woman’s death, continue to administer CPR and transport her to the hospital. Doctors may be able to perform a cesarean section, also known as a delivery via surgery, which could save the baby’s life.

Tip: If a pregnant trauma patient dies as a result of her injuries, it is important for you to understand the area’s policies and protocols involved in this difficult situation.

4. Normal Delivery
Calls concerning pregnancies are not typically emergencies; however, EMT-Basics should always be prepared to perform a delivery when they arrive on the scene. If the woman is not injured or experiencing signs or symptoms of predelivery issues, you should treat the woman as a stable medical patient.

a. Predelivery
When you arrive at the woman’s side, you must determine how quickly she will deliver her baby. Ask the patient when the baby is due. Find out how far apart the contractions are and if there is increasing pressure in the vagina. Examine the patient for bleeding or abnormal discharge. Feel the abdomen; if it’s hard, your patient is in the later stages of delivery. If you determine that you will not have enough time to transport the patient to a medical facility before she delivers her child, you’ll have to assist with the delivery on the scene.
If you must deliver the baby on the scene, the first thing you must do is take the proper body substance isolation precautions to protect yourself from the blood and bodily fluids you will encounter during the delivery. If delivery doesn’t occur within 10 minutes of deciding to deliver the child on the scene, call the medical direction physician and request permission to transport your patient to the nearest hospital.

b. Delivery
If you must deliver on the scene, be sure that your patient is lying on her back with her buttocks elevated. As the baby crowns, gently press on the perineum to ensure that the delivery doesn’t occur too quickly. A rapid delivery may lead to unsafe conditions for the mother and child. Be sure never to press on the fontanelles, the soft spots on the baby’s head. When the baby’s head appears outside the vaginal opening, ensure that the umbilical cord is not wrapped around the baby’s neck. If the cord is around the child’s neck, slide it off. If sliding doesn’t work, place two clamps on the cord and cut it before removing it from the child’s neck.
Next, gently guide the head downward until the first shoulder blade passes the pubic bone. Then, after ensuring you have a secure hold on the infant, guide the infant upward until the second shoulder passes. As your patient delivers the legs and feet, be sure to keep a firm grasp on the baby.
Pass the infant to your partner for evaluation and care while you assist the mother in the final stage of labor, which involves the delivery of the placenta. This process can take up to a half-hour to complete. Once the patient delivers the placenta, place it in a plastic bag and take it to the hospital for physicians to evaluate.

Tip: About 500 ml of blood is lost during a typical childbirth.

c. Care of Newborn
After delivery, EMTs must suction the newborn’s mouth and nose to remove fluids and allow for easier breathing. Dry and swaddle the newborn with a towel or blanket. Assess the infant’s health 1 minute and 5 minutes after birth using the APGAR scale. Check the newborn’s appearance, pulse rate, grimace, activity level, and respirations. Compare the scores from the 1-minute and 5-minute tests.

If the newborn is not breathing, stimulate the infant by massaging the baby’s back or flicking the souls of his or her feet. If the newborn doesn’t respond to stimulation, take resuscitative measures, as shown in the following figure.





Neonatal resuscitative measures pyramid.
If the newborn is still not breathing, call ALS and transport the infant and mother immediately.

5. Abnormal Delivery
While the majority of deliveries are normal, you must always be prepared to treat a patient experiencing an abnormal pregnancy or delivery. If the baby doesn’t appear to be in a cephalic (head-first) position, if meconium (fetal stool) is present, or if the delivery is premature, you must attempt to deliver or transport the patient immediately. Call ALS or the medical direction physician if you are unsure of how to proceed at any time.

a. Prolapsed Cord
A prolapsed cord is a condition in which the umbilical cord is the first body part out of the vagina during delivery. In this condition, the cord catches between the wall of the birth canal and the baby’s head, cutting off the baby’s oxygen supply. This condition requires immediate transport.
In the ambulance, elevate the patient’s pelvis and place her on high-flow oxygen. Direct her not to push, as the pressure will further cut off oxygen to the baby. Place your fingers into the vagina and gently move the baby’s head off the cord. Do not remove your hand until you reach the hospital. If the cord is sticking out of the vagina, dress it to maintain moisture.

Tip: In an instance of limb presentation, a leg or an arm may present itself similar to a prolapsed cord. The baby cannot be delivered in this position; therefore, treat the patient as you would for a prolapsed cord and transport her to a hospital immediately.

b. Breech Presentation
A breech presentation occurs when the baby is positioned feet first inside of the womb instead of head first. When a breech baby is delivered in a hospital, a surgical team is present in case the breech position creates complications. You must be prepared to deal with the possibility of a breech presentation. Many times, breech deliveries are similar to cephalic births; once the shoulders are through the birth canal, few complications arise. However, the possibility exists that the baby’s head may not deliver as quickly or easily as the rest of the body.
If the head is undelivered, the baby may suffocate, so take immediate action. With your palm up and your index and middle fingers spread apart, place your hand in the vagina between the baby’s face and the vaginal wall. Push the vaginal wall away from the baby’s face to allow for oxygen flow and deliver the head. If you cannot deliver the baby’s head, do not remove your hand and transport the patient to the hospital.

c. Multiple Births
Treat a patient giving birth to multiple babies the same as you would a patient delivering a single child. If you are aware of the multiple births before you arrive on the scene, you may choose to request assistance from a second EMS crew. After the delivery of the first baby, clamp or cut the first umbilical cord. The next baby may deliver before or after the patient delivers the first placenta. As the babies are born, warm them and assess their health. Be aware that multiple births typically produce smaller or premature babies, so you may need to work harder to regulate their body temperatures.

d. Premature Births
If an infant is born less than 37 weeks after being conceived or if the infant weighs less than 5.5 pounds, the infant is considered premature. Babies born early are often not fully developed in terms of their cardiovascular or respiratory systems. Because they cannot regulate their body temperatures and may not be able to breathe on their own, you need to pay close attention to their vital signs. Be sure to keep the infant wrapped in a warm, dry blanket or towel and administer oxygen if necessary. Immediately transport the patient and child to the hospital for emergency neonatal care.

6. Other Gynecological Emergencies
EMT-Basics are often called to the scene of an emergency involving vaginal bleeding, trauma to the external genitalia, or injuries after a sexual assault.
If a woman is experiencing vaginal bleeding not resulting from a trauma, you do not have to examine the genitalia. Obtain the patient’s SAMPLE history and ask the patient about the color of the blood, the number of sanitary pads she filled, and if she may be pregnant. Ask her if clots of tissue are present in the blood. While transporting the patient to the hospital, be prepared to treat her for shock.
If there is trauma to the external genitalia, provide treatment on the scene in a professional and efficient manner. As you treat the patient, remember to explain what you are doing and why you are taking such precautions or actions. If the patient is bleeding, apply pressure using a sanitary napkin or dressing. If the genitalia are swollen, apply an icepack wrapped in a towel to the area.

On the scene of a sexual assault, consider the fact that you may be the first person to care for the victim since she reported the crime. Keep your patient calm, reassure her that she is safe, and do not judge her as you gather SAMPLE information. You don’t need to examine the patient’s genitals if she doesn’t report extreme bleeding. If profuse bleeding occurs, it is often more comfortable for the patient if an EMT-Basic of the same sex performs the examination. Because the emergency scene is also a crime scene, work to preserve all evidence, including any on the victim. Do not instruct your patient to shower, urinate, douche, or clean any wounds as doing so might destroy valuable evidence. If you determine any injuries to be life threatening, don’t wait for the police to arrive on the scene to transport your patient.

Related Topics You Should Review:
- Contents of the childbirth kit
- Detailed procedures for normal and abnormal deliveries
- APGAR scoring system
- Resuscitative measures in normal and abnormal deliveries
- Delivery in the presence of meconium